GW1--02714_Well Construction - GW1_20240507

WELL CONSTRUCTION RECORD(GW;1) " �- . ' • For.Internal'Use Only: ; -
. 1:'Well Contractor Information:.: . - • ' • • • .: : • -
• . . . . . . •14:WATER ZONES; .. . .
Well Contractor Name •
FROM' . TO. DESCRIPTION
fG fG •
"
NC Well ContractorCertificdnonNumber : 55b �� •- 7'G `r,1n'1 •': •" ' : • • •
• IS.OUTER CASING(for multi-cased wells)OR-LINER(if ap licable) •'
. :•Aqua Will, inc,: • • •' • ' FROM." •TO'- ' •DIAMETER. THICKNESS./' .MATERIAL' '
•
•
•
Company Name. • •. • • — -At. '/fi.,,.i° — ,1a[..-1 :I�. Pia it..:.
� 16:INNER CASING OR TUBING(geothermal closed-loop):• "
. . 2..Well Construction Permit#:�.f I-2 ,0,2ip FROM - TO' • DIAMETER • THICKNESS• ' MATERIAL.•
4.riall applicable well conslraclion permits(1 e.UIC(_ounh•,.Stale Variance,.ete)'. .' - --
3.Well Use(check well.use): . • .. . : • : : ..'ft. . f.L: • Io,. •'.: . • :
Water Supply Well'. • : • . • 17.SCREEN .. .
• FROM... . TO • DIAMETER SLOT SIZE •THICKNESS MATERIAL. •'
.: Agricultural. . • . .: : .- . • -: : .. IliMunicipal/Public: - ' : . : . ' - . • ft.• ' tL' • • ":'in; • " ' .'
•
• .• . Geothermal(Heating/Cooling Supply) Residential Water Supply(single) . ft. . . rt.. • , in '
Industrial/Commt rcial; ResidentiahWaterSapply(shared) i&GROUT '
• ' Irrigation • : . , :. . : . ••' . .. :. • . : : :FROM " ' -TO -= MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water:Supply Well :•. " ".. . Q;.ft �O • ft
• • ' Monitoring . • : :.... �Recovciy: : : R ft. '�
• rt ►iE :Cl,1�5
'Injection Well: - .. -- •• • .. : - ft ..
Aquifer Recharge , DGroundwater'Remediation• :
Aquifer Storage and Recovery Salinity Bamer. •: -FROM - RAoL PACK MAOf pTERIAt1e) . 'EMPLACEMFTTMETHOD
AquiferTest A
q .. :.'. ::- Storinivater Drainage - : ":, • : :ft• •
' Experimental Technology ; - . " OSubsidence'Control • - - ' - ft.` • . - ft.- • : : --: .
: ' Geothermal(Closed Loop) • :• QTlacer
. • . . dtfloaal sheets If necessary.)•
20 DRiLLiNG LOG(attach ad .. .
: : • Geothermal(Heating/Cooling•Returnj••ii )Other(explain under.#21'Remarks)
FROM TO • " DFSCRIPTIOA(dolor:hardness;soNtnck Vim Warn dm ate4
. ' 4.Date Wells)Completed 7 /i "r c''T' Well ID# ft • ft• is • •• •
Se•WellLocatione . . . `, t l rj-ft p;. :
• ( t ? 1 �(JC >1Z�f1r14`
•
h o. ' ►'hi rwutrvi.V (,, t�,: ft;.
acility Owt Name ,' •
. ": .
: • Facility ID#(ifappiicablo) ft. ( --�• r ' . .,
,i•O' c gz saR it i�o , 7t . ' • •• . ' - . •
Physical Address;City and Zip • ' . .. . : .tt. a IVIA Y .t/ i':LUG4: .
2A),1Cre. 21•RE•MARKS
ty Parcel Identification No.(PIN) ,t, :`
: Sb.Latitude:and longitude In degrees/minutes/seconds'or decimal degrees: - - ' '
(if well field:ono:lat/long is auffiotent)
2.:Certiftc tion:.' r
6.Is(are)the well(s) ermanent or. DTemporary : . . Signature of C.--.- -d.Won Con cwr r j , • Da(n .- • -
. • -Bi rignbig.i/dr faint,1 herehr earl//i tltat the urf/(.r)tress(ware)crnrtntcted'In acconlaace
a
. 7.Is this repair to an.existing well:' DY.es or No :;Wilt ISA NCAC 02C.0100 or 15.4 NCAC 62C.0?00 i5'ell ConsMtcilon Standortk anti that a
11 Ids is a rcralr,flBrnu knos,uel/coacm at lion lnfitnitatian and eriilaln ihe Ib iurc of the cviptoJ lhLr reran!liar hi.edpraridcd in the dill anne,
: repair nntlar't12I remarks set dirt or on the back of t,i f firm..
. 23.Site diagram or additional well details: ' •• • "
'8.For Gcoprobe/DPT or Closed-Loop'Geothermal Wells having the same •.You,may use the back.of this page to provide additional well site details or well..
.construction,"only I GW-I is needed: Indicate TOTAL NUMBER of wells • • . construction details. You may yalso''attach additional pages if necessary- • • "
drilled: . ,
•
SUBMITTAL INSTRUCTIONS
' 9.Total well depth below land surface:. (o sign (ft) ..24a.For All"Wells: Submit this form within 30'days'of.completion of well '
For mobil a wells list aH depths IfdiJjeirnl(erantple 3(a)200'and 2( 1.0.0.) • construction to the following: • ' •
' 10.Static water level below top of casing: • - • (ft.). . .Dl ision of Water Resources,Information Processing Unit,-
• If nnterletrl fs itboFt!tithing;use +," • • : - 1617 Mail Service Center,Raleigh;NC 27699-1617 :
II.Borehole diameter: tt7 :•(in.)
ii .
12.Well construction method: l r;�' Wells:copy of this form swithin 30 theays of comp etio of well '
246'For Iniec..
(i.e:auger,rotary,cable,direct push,etc,) ' .
above,'also submit on
consyuction.to the following:
Division of.Water:Resources,Underground Injection.Control Program, - : .
FOR WATLl2 SUPPLY WErits ONIS: • - •1036 Mall Service Center,Raleigh,NC 276994636 .' •
13a.'Yield('pm) . ). .Method of test 5a�in a' ' 24c.For Water Supply&Injection Wells: In addition to sending the form to • •
•/� P 1 the-address(es) above, also'submit lone copy of this form within 30 days of
13b.Disinfeetlon type: :11'!/ • : 'Amount:)(o OZ- completion of well construction to the county health department of the county.
. • - . : . . - .where constructed. -
Forrt GW-I ' North Camlinn rlennrinvnt nr Fnbimmmnionl n,,,,nw-na,::.:...,..rvt..•..la.....a.:......